1. Introduction for speaker only • Please see speaker notes below for details of format of this presentation and suggestions on how it might be used

2. Criteria and indicators of best practice in clinical audit

3. Clinical audit cycle

4. Stages of clinical audit cycle • Stage 1 – Preparation & planning • Stage 2 – Measuring performance • Stage 3 - Implementing change • Stage 4 – Sustaining improvement (including re-audit)

5. Stage 1 Preparation and Planning • Criterion 1 • The topic for the clinical audit is a priority • Indicators • 1.1 Topic reflects a local service, specialty or national priority where care could be improved or refined through clinical audit • 1.2 Key stakeholders, clinical and non-clinical, agree that topic is a priority

6. Stage 1 Preparation and planning • Criterion 2 • The clinical audit measures against standards • Indicators • 2.1 Standards are based on best available evidence • 2.2 Standards are referenced to source and link provided • 2.3 Standards are agreed by clinical audit team, clinicians and patients • 2.4 Standards are expressed in a form that enables measurement

7. Stage 1 Preparation and planning • Criterion 3 • The organisation enables the conduct of clinical audit • Indicators • 3.1 Written plan describes structures and processes to support clinical audit • 3.2 Staff have time to participate • 3.3 Organisation provides administrative and practical support • 3.4 Necessary training is identified and provided • 3.5 Financial costs are identified and met

8. Stage 1 Preparation and planning • Criterion 4 • The clinical audit engages with clinical and non-clinical stakeholders • Indicators • 4.1 All clinical disciplines relevant to audit topic should be involved • 4.2 Senior clinicians show commitment and provide leadership • 4.3 Ownership of clinical audit findings at most senior level where there is power to implement change • 4.4 Stakeholder roles and accountabilities are clearly defined • 4.5 Stakeholders are involved from beginning to end • 4.6 Active communication is maintained throughout the process

9. Stage 1 Preparation and planning • Criterion 5 • Patients or their representatives are involved in the clinical audit if appropriate • Indicators • 5.1 Patient group to whom standards apply is clearly defined • 5.2 Standards include patient priorities and patient-defined outcomes • 5.3 Patients/carers are recognised as key stakeholders • 5.4 Patient members of clinical audit team are fully informed about what is expected of them.... • 5.5 .....and are given basic training as necessary • 5.6 Patients are kept informed about timescales, progress, results and actions

10. Stages of clinical audit cycle • Stage 1 – Preparation & planning • Stage 2 – Measuring performance • Stage 3 - Implementing change • Stage 4 – Sustaining improvement (including re-audit)

11. Stage 2 Measuring performance • Criterion 6 • Clinical audit method is described in written protocol • Indicators • 6.1 Timetable for clinical audit is described including completion and re-audit • 6.2 Protocol describes methodology & data collection process in detail • 6.3 Consideration given to ethics, confidentiality & consent and Caldicott principles applied • 6.4 Methods are recorded so that re-audit can be undertaken

12. Stage 2 Measuring performance • Criterion 7 • Target sample should be appropriate to generate meaningful results • Indicators • 7.1 method of sampling best suited to measuring performance against standards and scientifically reliable • 7.2 sample size sufficient to generate meaningful results • 7.3 sample allows for adjustment for case mix

13. Stage 2 Measuring performance • Criterion 8 • Data collection process is robust • Indicators • 8.1 clinical audit utilises pre-existing data sets where possible • 8.2 data collection tool and process have been validated • 8.3 data collection process aims to ensure complete data capture

14. Stage 2 Measuring performance • Criterion 9 • Data analysed & results reported in way that maximises impact of clinical audit • Indicators • 9.1 data analysed & feedback of results given within agreed timescale to maintain momentum • 9.2 results presented appropriately for each audience to ensure that they stimulate & support action planning • 9.3 results are communicated effectively to all key stakeholders including patients

15. Stages of clinical audit cycle • Stage 1 – Preparation & planning • Stage 2 – Measuring performance • Stage 3 - Implementing change • Stage 4 – Sustaining improvement (including re-audit)

16. Stage 3 Implementing change • Criterion 10 • Action plan is developed and implemented to take forward any recommendations made • Indicators • 10.1 plan to include both areas needing attention & those with good compliance • 10.2 plan to have agreement of stakeholders including patients • 10.3 plan highlights who is responsible for each action with timescales • 10.4 plan identifies financial/resource implications • 10.5 results & action plan is communicated widely • 10.6 implementation is closely monitored and progress regularly communicated

17. Stages of clinical audit cycle • Stage 1 – Preparation & planning • Stage 2 – Measuring performance • Stage 3 - Implementing change • Stage 4 – Sustaining improvement (including re-audit)

18. Stage 4 Sustaining improvement • Criterion 11 • Clinical audit is cyclical process that demonstrates that improvement has been achieved & sustained • Indicators • 11.1 topic is re-audited to complete clinical audit cycle • 11.2 where recommended action is not achieved topic is re-audited at agreed intervals • 11.3 results of re-audit are recorded and disseminated appropriately including to patients

19. HQIP website

20. HQIP website

21. Contact us Healthcare Quality Improvement Partnership Email - lqit@hqip.org.uk Website - www.hqip.org.uk Promoting quality improvement for better healthcare